Provider Demographics
NPI:1255633699
Name:CIRCLE OF LIFE OUTREACH SERVICES
Entity type:Organization
Organization Name:CIRCLE OF LIFE OUTREACH SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LAWANDA
Authorized Official - Middle Name:
Authorized Official - Last Name:DRAYTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:734-961-2409
Mailing Address - Street 1:15491 TROESTER
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48205
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:15491 TROESTER ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48205-3566
Practice Address - Country:US
Practice Address - Phone:734-961-2409
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-17
Last Update Date:2010-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health